Encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía / National survey on postoperative care and treatment circuits in neurosurgery

Introducción. El análisis de los procesos quirúrgicos debe ser un estándar de los sistemas de salud. Describimos el circuito de atención y tratamiento postoperatorio para intervenciones neuroquirúrgicas en los centros de nuestro país. Material y métodos. Desde junio a octubre de 2014 se difundió una encuesta a jefes de Anestesiología de 73 hospitales españoles con neurocirugía y a miembros de la Sección de Neurociencia de la SEDAR, sobre tratamientos perioperatorios y sobre los circuitos postoperatorios tras procedimientos neuroquirúrgicos. Resultados. Obtuvimos 45 respuestas de 30 centros (41,09%). Un 60% de los anestesiólogos realiza tratamiento preventivo analgésico locorregional; la intensidad del dolor es evaluada sistemáticamente por un 78%. Las combinaciones de paracetamol, antiinflamatorios no esteroideos y morfina son las más utilizadas. Un 51,1% conoce la incidencia de NVPO tras craneotomía y el 86,7% considera necesaria la profilaxis multimodal. La dexametasona se administra como antiemético (88,9%) y/o tratamiento antiedema (68,9%). Un 44,4% de los anestesiólogos administra sistemáticamente profilaxis anticomicial en pacientes con tumores supratentoriales (levetiracetam, 88,9%). El 73,3% de los anestesiólogos disponen de protocolos de vigilancia postoperatoria. El anestesiólogo (73,3%) es quien decide el destino del paciente, que suele ser UCI (83,3%) o URPA (50%). La monitorización neurológica en el postoperatorio varió según el tipo de intervención, si bien la fuerza y la sensibilidad se exploraron en el 70-80%. Conclusiones. Existe una gran variabilidad en las respuestas, probablemente atribuible a la ausencia de guías, diferentes estructuras y equipamiento hospitalario, tipo de cirugía y personal cualificado. Necesitamos protocolos consensuados para estandarizar el tratamiento y el grado de monitorización necesaria durante el postoperatorio (AU)

Introduction. The analysis of surgical processes should be a standard of health systems. We describe the circuit of care and postoperative treatment for neurosurgical interventions in the centres of our country. Material and methods. From June to October 2014, a survey dealing with perioperative treatments and postoperative circuits after neurosurgical procedures was sent to the chiefs of Anaesthesiology of 73 Spanish hospitals with neurosurgery and members of the Neuroscience Section of SEDAR. Results. We obtained 45 responses from 30 centres (41.09%). Sixty percent of anaesthesiologists perform preventive locoregional analgesic treatment. Pain intensity is systematically assessed by 78%. Paracetamol, non-steroidal anti-inflammatory and morphine combinations are the most commonly used. A percentage of 51.1 are aware of the incidence of postoperative nausea after craniotomy and 86.7% consider multimodal prophylaxis to be necessary. Dexamethasone is given as antiemetic (88.9%) and/or anti-oedema treatment (68.9%). A percentage of 44.4 of anaesthesiologists routinely administer anticonvulsive prophylaxis in patients with supratentorial tumours (levetiracetam, 88.9%), and 73.3% of anaesthesiologists have postoperative surveillance protocols. The anaesthesiologist (73.3%) decides the patient's destination, which is usually ICU (83.3%) or PACU (50%). Postoperative neurological monitoring varied according to the type of intervention, although strength and sensitivity were explored in between 70-80%. Conclusions. There is great variability in the responses, probably attributable to the absence of guidelines, different structures and hospital equipment, type of surgery and qualified personnel. We need consensual protocols to standardize the treatment and the degree of monitoring needed during the postoperative period (AU)

National survey on postoperative care and treatment circuits in neurosurgery. / Encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía.

INTRODUCTION: The analysis of surgical processes should be a standard of health systems. We describe the circuit of care and postoperative treatment for neurosurgical interventions in the centres of our country. MATERIAL AND METHODS: From June to October 2014, a survey dealing with perioperative treatments and postoperative circuits after neurosurgical procedures was sent to the chiefs of Anaesthesiology of 73 Spanish hospitals with neurosurgery and members of the Neuroscience Section of SEDAR. RESULTS: We obtained 45 responses from 30 centres (41.09%). Sixty percent of anaesthesiologists perform preventive locoregional analgesic treatment. Pain intensity is systematically assessed by 78%. Paracetamol, non-steroidal anti-inflammatory and morphine combinations are the most commonly used. A percentage of 51.1 are aware of the incidence of postoperative nausea after craniotomy and 86.7% consider multimodal prophylaxis to be necessary. Dexamethasone is given as antiemetic (88.9%) and/or anti-oedema treatment (68.9%). A percentage of 44.4 of anaesthesiologists routinely administer anticonvulsive prophylaxis in patients with supratentorial tumours (levetiracetam, 88.9%), and 73.3% of anaesthesiologists have postoperative surveillance protocols. The anaesthesiologist (73.3%) decides the patient's destination, which is usually ICU (83.3%) or PACU (50%). Postoperative neurological monitoring varied according to the type of intervention, although strength and sensitivity were explored in between 70-80%. CONCLUSIONS: There is great variability in the responses, probably attributable to the absence of guidelines, different structures and hospital equipment, type of surgery and qualified personnel. We need consensual protocols to standardize the treatment and the degree of monitoring needed during the postoperative period.

Anestesia general intubada en primates para cirugía otoneurológica experimental / General anesthesia by intubation in primates in experimental otoneurologic surgery

Introducción: En este trabajo aportamos nuestra experiencia en el manejo anestésico y quirúrgico de primates (M. fascicularis) en un procedimiento de cirugía otoneurológica experimental. Material y Métodos: Veintiún primates adultos fueron sometidos a la sección translaberíntica del VIII par craneal. Seguidamente, en 14 animales se colocó unilateralmente un prototipo de implante auditivo en el tronco cerebral para estimular en superficie a los núcleos cocleares. Como medicación pre-anestésica se usó una mezcla en inyección intramuscular de clorhidrato de ketamina, midazolam y sulfato de atropina. El procedimiento quirúrgico se realizó bajo anestesia general con intubación, conseguida tras la administración de propofol (1.5 mg/kg) y mantenida con óxido nitroso y halotano. Resultados: La mezcla de clorhidrato de ketamina, midazolam y sulfato de atropina produjo una anestesia profunda en 4ñ1.7 minutos, lo que permitió la manipulación segura de los animales. La intubación nasotraqueal atraumática, evitando el uso de miorrelajantes, fue posible en todos los animales sin dificultades. Los animales se mantuvieron adecuadamente anestesiados, sin presentar incidencias destacables durante la cirugía, y fueron extubados a los 10ñ2.5 minutos después del cese de la administración de óxido nitroso y halotano. Tampoco hubo complicaciones destacables desde el punto de vista quirúrgico. Conclusiones: Aportamos una técnica anestésica que proporciona una inmovilización y anestesia óptimas para el trabajo otoneurológico experimental con primates. Esta técnica permite una rápida recuperación anestésica y suprime el uso de relajantes musculares para la intubación, por lo que podría ser usada de forma segura en otros tipos de procedimientos quirúrgicos (AU)

Uniportal endoscopic superior thoracic sympathectomy.

OBJECTIVE: A retrospective study presenting our experience with upper thoracic endoscopic sympathectomy in patients with primary palmar hyperhidrosis. METHODS: One hundred patients (46 women and 54 men) underwent bilateral uniportal endoscopic thoracic sympathectomy since January 1, 1995. Age distribution ranged from 12 to 54 years (mean, 23.4 yr). RESULTS: Sympathectomy on both sides was accomplished within 30 minutes in a single stage. Ninety-six patients (96%) had an uneventful postoperative course and were discharged the following day. Four patients with residual hemothorax required intercostal drainage and were discharged on the third postoperative day. Ninety-six patients were completely satisfied with immediate and permanent relief of palmar perspiration. Compensatory hyperhidrosis was the major complication, which was usually mild and tolerable after reassurance. In only eight patients (8%) was the compensatory hyperhidrosis considered bothersome, requiring treatment with aluminum chloride in ethanol solution at 25%. There was no mortality. Recurrence of palmar hyperhidrosis has been noticed in five patients (5%) during the follow-up period (range, 2-56 mo; mean, 12 mo). At the time of reoperation, a remaining branch of the sympathetic chain could be observed and coagulated. CONCLUSION: We consider thoracoscopic sympathectomy to be a simple, safe, and effective method for treating palmar hyperhidrosis. It is an effective method for treating patients with palmar hyperhidrosis, with a shorter operation time, fewer hospital days, and a better cosmetic result, as compared with the open approaches.

Operative monitoring of hand and axillary temperature during endoscopic superior thoracic sympathectomy for the treatment of palmar hyperhidrosis.

OBJECTIVE: To find out how much the temperature in the palm rises after upper thoracic sympathectomy for palmar hyperhidrosis, and correlate the temperature with the outcome. DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 73 patients (34 women and 39 men, age range 16-42 years, mean 26) who were operated for palmar hyperhidrosis between 1 January 1995 and 31 December 1997. INTERVENTIONS: Bilateral thoracic endoscopic sympathectomy during which the temperature was monitored on the skin of both axillae and thenar eminences, and in the oesophagus. MAIN OUTCOME MEASURES: Morbidity, alleviation of hyperhidrosis, recurrence rate, and differences in temperature postoperatively. RESULTS: There was minor bleeding during operation in 25 cases (34%), but in only 4 was it sufficient to require insertion of a drain; 2 patients developed transient Homer's syndrome; but the most common complication was compensatory hyperhidrosis (n = 52, 71%). In only 5 was this other than mild and required treatment with aluminium chloride in ethanol 25%. Palmar hyperhidrosis was alleviated in all cases, axillary sweating was considerably improved, and there was improvement in the feet in 56 (77%). There were 5 recurrences, all on the right side, during a mean follow up of 9 months (range 2-36), but in no case was the sweating severe. In almost all cases the temperature of the palm was less than that of the axilla before operation by a mean (SD) of 0.9 (0.3) degrees C. The rise in temperature varied from 1.7 (0.4) degrees C to 2.6 (0.4) degrees C. In the 5 patients who developed recurrences the increase was less (0.5 (0.4) degrees C). CONCLUSION: Thoracic endoscopic sympathectomy is safe, simple, and effective in treating palmar hyperhidrosis that has not responded to conservative treatment. Intradermal monitoring is an accurate and cost-effective way of monitoring temperature during operation. Although it is essential to achieve a rise in temperature of 1 degrees C, our most important finding was that the final temperature in both hands and axillae should be above 35 degrees C and as near as possible to 36 degrees C.

[General intubation anesthesia in primates for experimental otoneurologic surgery]. / Anestesia general intubada en primates para cirugía otoneurológica experimental.

INTRODUCTION: We report our experience in anaesthetic and surgical management of primates (M. fascicularis) in an experimental otoneurosurgical procedure. MATERIAL & METHODS: The VIII cranial nerve was bilaterally sectioned in a translabyrinthine approach in 21 adult primates. In 14 animals subsequently, a prototype of auditory brainstem implant was placed unilateraly within the brain stem for surface stimulation of cochlear nuclei. Premedication consisted in an intramuscular mixture of ketamine, midazolam and atropine. Surgical procedure was performed under intubated general anaesthesia, after propofol (1.5 mg/kg) administration and maintained with nitrous oxide and halotane. RESULTS: The mixture of ketamine, midazolam and atropine produced a deep anaesthesia in 4 +/- 1.7 minutes, permitting safe animal handling. Atraumatic nasotracheal intubation without muscle relaxing agents was easily achieved in all animals. Anaesthesia was adequately maintained with nitrous oxide and halotane. Animals did not present any relevant incidents during surgery, and were extubated 10 +/- 2.5 minutes after cessation of gas administration. Post-operatively, no relevant surgical complications occurred. CONCLUSIONS: We report an anaesthetic technique that provides an optimal restrain and anaesthesia for experimental otoneurosurgical procedures with primates. This technique offers a quick recovery and avoids the use of muscular relaxing agents for intubation, and thus could be safely used in other kind of surgical procedures.

[Neural tube dysfunction and cutaneous lesions]. / Defectos del tubo neural y lesiones cutáneas.

The aim of our article is to underline the cutaneous lesions accompanying spinal disraphysm. We would like to stress the responsibility of physicians, particularly dermatologists, pediatricians, orthopedic surgeons, urologists, neurologists and neurosurgeons to recognize as early as possible these cutaneous stigmata. In this way patients will be studied and treated as soon as possible. No cutaneous lesion in the posterior middle line of the back or close to it should be removed until any possibly associated malformation has been thoroughly studied. Otherwise the diagnosis of a subyacent spinal disraphysm might be unduly delayed and thus allow the appearance of irreversible neurological deficits. Cutaneous lesions associated with spinal disraphysm are: areas of atrophic skin, aplasia cutis congenita, congenital skin scars, dermal pits, dermal sinuses, dyschromic lesions, hyperpigmented lesions, abnormal pilifications, vascular lesions, subcutaneous lipomas, polipoid lesions simulating tails, neurofibromas, melanocitic nevus and some lesions of tumoral origin. Of there the most common cutaneous lesion associated with spinal disraphysm is the lipoma, followed by the dermal sinuses, the anomalus pilifications and the angiomas.

Surgical technique for cranio-cervical decompression in syringomyelia associated with Chiari type I malformation.

Our purpose is to present our results with the surgical treatment of syringomyelia associated with Chiari type I malformation. Between October 1989 and October 1995, twenty-eight patients underwent a sub-occipital craniotomy and a C1 laminectomy. After dura mater opening the cerebellar tonsils were mobilised. Neither catheter, nor plugging of the obex, nor tonsillar tissue removal was performed. The dura mater was enlarged by means of a wide graft to create a new cisterna magna of adequate size. Postoperative MRI scans showed an ascent of the cerebellum of 4.3 +/- 4.8 mm (measured by the fastigium to basal line), as well as of the brainstem (mean migration of the mesencephalon-pons junction of 4.3 +/- 3.3 mm). The tonsils emigrated cranially 6.5 +/- 4.8 mm. While preoperative mean syringo-cord ratio was 66.3% +/- 13.3, post-operatively was 12.1% +/- 12.7 (p < 0.0001). A complete collapse of the syrinx was observed in 39% of the patients. Long-term improvements were obtained in 73% of the cases and 27% were unchanged. No patient got worse. We conclude that in the treatment of syringomyelia associated with Chiari I malformation an artificial cisterna magna of sufficient size must be created. This is achieved by means of an extensive sub-occipital craniotomy and C1 laminectomy, followed by dural opening. Small bone removal with limited enlargement of the posterior fossa often results in failures of treatment and recurrences. Tonsillar removal is not necessary to obtain a good reconstruction of the cisterna magna.

Use of frozen cranial vault bone allografts in the repair of extensive cranial bone defects.

In cranioplasty complexity is proportional to the size of the detect, particularly if greater than 50 cm2. If the patient's own bone flap is not available, allogenic frozen bone graft can be used instead. Between June 1990 and June 1995 twenty cranioplasties with allogenic frozen bone grafts were performed. Age of patients ranged between 23 and 63 years (average 38.4 years). Male/female ratio was 2:1.7. Size of craniectomy ranged between 65 and 150 cm2 (average 83.3 cm2). Follow-up ranged between 10 and 58 months (average 41 months). Donors were tested to rule out transmissible diseases, infections, sepsis and/or cancer. Bone grafts were removed under aseptic conditions, microbiological cultures were taken, wrapped in a gauze soaked with Gentamicin sulphate and Bacitracin, sealed in three sterilised vinyl plastic bags, and stored in a deep freezer for a minimum of 30 days (range 36-93 days, average 67 days), at a temperature of -80 degrees C. Grafts were placed in the defect after a step was carved on its borders to facilitate the contact between host and graft. Vancomycin 1 g. IV/12 hours and Ceftriaxone 1 g. IV/12 hours were administered for five days. Grafts were covered by means of scalp flaps. Only one required a musculocutaneous free flap. None was exposed, extruded or had to be removed. Plain skull X-ray studies showed progressive remodelling of the grafts. Partial resorption was observed in two (2/20, 10%) and loss of thickness in another 3/20 (15%), but with no changes in the contour. Biopsies were taken in 3/20 (15%) cases at a second surgical procedure. Areas of osteoclastic resorptive activity mixed with others of osteoblastic bone apposition, showed replacement with new bone. We conclude that cranial vault frozen allografts are a good alternative to autologous bone when the latter is absent or not present in sufficient amount.

Cranioplasty with autogenous autoclaved calvarial bone flap in the cases of tumoural invasion.

When a bone flap is raised in the course of a craniotomy, the ideal is to replace it at the end of the procedure. When it is invaded by tumoural cells, it cannot be replaced due to the risk of tumoural recurrence. In these cases we have autoclaved the bone flap to be able to replace it with no fear of tumoural recurrence. Between October 1989 and October 1995 sixty-two patients required autoclaving of the bone flap in the course of a craniotomy due to tumoural invasion (thirty-five meningiomas, sixteen bone tumours, five metastases, and eight scalp tumours). The infiltrated bone flaps were removed, cleaned, autoclaved for 20 minutes at 134 degrees C and 1 kg/cm2 and re-implanted. Patients were followed-up for 10 to 58 months (average 41 months). At every follow-up visit skull x-ray studies, clinical examination, and photographs were done. When needed a CT scan was performed to assess the thickness of the bone flap. On follow-up roentgenograms partial resorption was observed in twelve cases (19.3%). CT scan studies showed loss of thickness in another thirty-five cases (56.4%). Meanwhile the external aspect remained unchanged. In six cases (3.2%) biopsies of the bone flaps were taken at a second surgical procedure. They showed newly formed bone partly re-populated by osteocytes but retaining areas of sequestered bone. We conclude that autoclaved bone, if replaced with direct contact with living bone, it is gradually repopulated with osteocytes. Cranial vault autoclaved autologous bone flap is a good alternative when the original bone flap is invaded but not destroyed by tumoural cells.

Surgical treatment of anterior skull base tumours.

Skull base tumours represent a special challenge to surgeons due to the complex anatomy of the area. While small tumours are easy to remove, large lesions can pose complex situations. The most difficult aspects are not only the approach and removal, but specially the repair of the defects created by the resection of the tumour. We present here our experience with the surgical removal of tumours on the anterior skull base. To achieve a good approach, we resort to a bifrontal craniotomy including the cilliar arches. To obtain a skull base bone flap that can be used for repair at the end of the procedure, we remove the roof of the nose and a part of the medial wall and roof of both orbits. While the tumour is removed, the skull base bone flap is autoclaved to kill all tumoural cells. At the end of the procedure this bone flap is replaced, wrapped with a flap of pericranium. Provided no orbit needs to be emptied, no other flap is needed to reconstruct the area. One advantage is that the surgical cavity is not occluded with tissues, thus facilitating early identification of any recurrence. The area can be explored with the aid of an endoscope introduced into the nasal cavities through the nostrils, and in case of doubt, biopsies taken from all suspicious area. Our technique facilitates the repair of the surgical defect, and while not compromising the healing process it has a very low incidence of CSF leaks and infections.

Dorsal root repair by means of an autologous nerve graft: experimental study in the rat.

Rat dorsal root regeneration was studied after 6th and 7th cervical root surgical removal and replacement with an autologous graft of peripheral nerve harvested from the surval nerve from dorsal root ganglion to dorsal horn. Histological studies showed axonal regeneration within the grafts. When the distal end of the graft was placed inside the posterior horn of the spinal cord by use of a myelotomy, axonal sprouts (revealed by the transganglionic staining method of horseradish peroxidase or HSP) reached the neurones of the posterior horn in a limited fashion.

Surgical treatment of insular gliomas.

Surgical treatment of glial tumours arising in the insula is specially challenging due to the proximity of the internal capsule. Although small insular gliomas have been removed safely by a transylvian approach, in large dominant insular tumours only biopsy has been recommended to avoid postoperative deficits. Unfortunately that is a suboptimal form of treatment as low grade supratentorial gliomas should be removed radically to prevent tumour progression, malignization and to increase the recurrence-free-interval. Addition of radiotherapy to partial removal is associated with a much higher incidence of recurrences and early malignizations compared to radical removal and no radiotherapy. Between 1st October 1989 and 1st September 1996 we treated twenty-three patients harbouring insular gliomas. To increase the radicality of the resection the surgical procedure was performed under local anaesthesia whenever possible, as general anaesthesia usually leads to more conservative resections. In 20/23 (86.9%) patients complete resection was accomplished, and subtotal in three (13.1%). The removed tumours were: two oligodendrogliomas, five grade I astrocytomas, nine grade II, four grade III and three grade IV. Postoperative neurological deficits occurred in five patients. Four suffered a hemiparesis (that recovered in an average of 6 months) and one a motor dysphasia which took a week to recover. Two of the seventeen patients operated on for low grade insular gliomas underwent malignant change. We conclude that complete surgical removal of insular gliomas should be considered and at least attempted in all cases.

Duraplasty with freeze-dried cadaveric dura versus occipital pericranium for Chiari type I malformation: comparative study.

During the period from October 1, 1989 to October 1, 1995 a total of 26 cases of Chiari type I malformation not associated with syringomyelia were attended in our Hospital. All patients underwent cranio-cervical decompression, with occipital craniectomy and removal of the posterior arch of C1. In 3/26 (11.5%) cases an additional C2 laminectomy had to be performed and in 1/26 (3.8%) case the C3 laminae were also removed. A first group of 13 patients underwent dural repair with freeze-dried cadaveric dura sutured with continuous 4-0 Vicryl running stitches, reinforced with fibrin sealant (Tissucol). A second group of 13 patients underwent duraplasty with autogenous occipital pericranium also sutured with continuous 4-0 Vycril but no fibrin sealant at all was added. In the first group, in which freeze-dried cadaveric dura plus Tissucol was used, there were 2/13 (15.3%) cases of CSF leak, requiring some additional skin stitches to stop the leak. In 5/13 (38.4%) cases there were notorious subcutaneous CSF accumulations that required repeated punctures plus compressive bandage. In 6/13 (46.1%) pseudomeningoceles appeared that took a year to clear completely. In the 13 patients who underwent dural repair with autogenous occipital pericranium watertight closure was achieved with sutures only, no fibrin sealant was added at all. Neither CSF leaks through the wound nor subcutaneous CSF accumulations were noted. We conclude that, in our hands, autologous pericranium taken from the occipital area, gives better results than freeze-dried cadaveric dura mater in duraplasty for surgical repair of Chiari type I malformation.

Shunt malfunction in relation to shunt infection.

Ventriculo-peritoneal shunt malfunction may be caused by shunt infection which may not be clinically apparent as the cause of the malfunction by standard diagnostic criteria. This suggests that the real incidence of infected shunts might be higher than previously suspected. In order to study the relationship between infection and shunt malfunction, we followed a protocol over five years (54 V-P shunts) consisting of (1) removal of the malfunctioning shunt and replacement in the same surgical procedure with a new one or institution of an external ventricular drainage for 8 days (if there were clear signs of infection), (2) culturing of CSF and every part of the removed shunt, and (3) intravenous antibiotic treatment (Vancomycin 1g./12h + Ceftriaxone 1g./12h) for five days after the new V-P shunt had been inserted. In those cases in which an external ventricular drainage had been placed, its tip and a portion of the new V-P shunt were also cultured. The results showed that although CSF cultures were negative in 49/54 cases (90.7%), cultures of the removed shunts were positive in 32/54 (59.2%), most of them (21/32, 65.6%) for Staphylococcus coagulase negative organisms. The CSF samples obtained by puncturing the reservoir on admission to Hospital were positive only in 5 out of 54 cases (9.2%), only in those showing clinical features of infection. In the remaining cases, 27 out of 54 (50%) the CSF cultures were negative but the shunt cultures proved positive and required further treatment. For the newly inserted shunts (173) CSF was collected through the shunt during the surgical procedure, and a small piece of the extra-tube from the ventricular and from the peritoneal catheter were obtained and cultured. All the six shunts (6/173, 3.4%) that showed positive cultures after insertion had to be replaced within a period of three to four weeks due to malfunction (range 26 +/- 7 days), indicating that the systematic culture of CSF and tubing helps to predict which shunts will soon need to be replaced due to infection. We conclude that CSF culture alone does not rule out infection in cases of shunt malfunction. The percutaneous CSF obtained from the shunt reservoir admission is particularly prone to show negative cultures even when the shunt is colonized by bacteria.